Solomon Islands health system review
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The Solomon Islands HiT determines that the country’s health system has significant weaknesses but also considerable strengths. Despite the range and difficulty of issues facing policy-makers in the Solomon Islands, there have been significant achievements in health, including considerable progress in advancing population health status. The performance of the health system is positive, achieving high coverage, high satisfaction levels, and steady progress on health outcomes. Nonetheless, the country faces important health challenges that could undermine development gains made to date
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Solomon Islands health system review
- 1. Health Systems in Transition Solomon Islands Health System Review
- 2. 2 Authors: Nicola Hodge Beth Slatyer Linda Skiller Editors: Maxine Whittaker Health Systems in Transition: Solomon Islands Health System Review Suggested citation: Hodge N, Slatyer B, Skiller L. Solomon Islands Health System Review. Vol.5 No.1. Manila: World Health Organization, Regional Office for the Western Pacific, 2015.
- 3. Solomon Islands: Socio-demographic profile Overview of health system Service delivery network Governance and administration Financing Major reforms Infrastructure Human Resources Main findings Progress made Remaining challenges Future prospects 3 Presentation outline: This map is an approximation of actual country borders Source: https://www.who.int/countries/slb/en/
- 4. 4 Socio-demographic profile Area 28370 sq. km More than 900 islands and atolls Population • 515870 (2011) • 80% Rural population • 4.1 TFR (2013) Life expectancy at birth m/f 66/69 (2012) GDP per capita: USD 3455 (PPP, current) HDI 152 Expenditure on health % GDP 8% (2012) Source: Secretariat of the Pacific Community, 2014 Solomon Islands population pyramid 2013
- 5. 5 Unified, blended system 1.1. Government as steward and manager 2.2. On track for UHC 3.3. Government and donor financed 4.4. Prevention and primary care focused Overview: Health system 1. Minimal private sector and NGO involvement 2. Minimal OOP payments 3. Service provision reflecting population distribution 4. Efficient workforce structure/nurse-led
- 6. Overview: Service delivery Patient pathways: Formal referral system often bypassed Outpatient care: Contact rates are high compared to regional neighbors. 87% seek care when ill Public health activities integrated into primary care Shortage of clinical equipment and medical supplies: NRH only has staff and equipment to conduct diagnostic tests on malaria 6 Human resources: Nurse-led primary care system with referral to doctors: Critical shortage of health workers Inpatient care Limited inpatient care in area health centres, patients often referred to provincial hospitals or NRH Specialist care at NRH from national level clinicians or invited specialists Public hospital inpatient & outpatient care use distributed equally between richest and poorest quintiles The regional eye centre in the National Referral Hospital in Honiara. ©WHO/Yoshi Shimizu
- 7. 7 • Funder, regulator and provider of nearly all services • Ministry of Health and Medical Services – leading central organisation National • Delivery of primary health care and outreach programmes Provincial Health Offices • NGO and faith based organizations: Funding and service delivery, largely in collaboration with MHMS • Private sector has a minimal role in health system. No formal consumer or consumer advocacy groups exist Other Overview: Governance and Administration
- 8. 8 Overview: Health Financing Moderate levels of expenditure relative to national income Government and donor funding majority financing Minimal OOP and catastrophic spending Strained fiscal space with high barriers to increased health spending • THE as proportion of GDP doubled from 4.1% in 1991 to 9% in 2012 • Overall health expenditure tripled from 1995-2011 • 95% government and donor financing • OOP payments and catastrophic spending are the lowest compared to East Asia and Pacific region, possibly resulting in high utilization • Slowing economic growth and logging revenues limiting growth in fiscal spending
- 9. 9 Overview: Major reforms • 2008 – Sector-Wide Approach (SWAp) • Building MHMS leadership and technical effectiveness with donor support • 2010 – National Health Strategic Plan 2011-2015 Key goals: • Universal Health Coverage • Decentralization of national programmes • Efficiency at NRH • Human resources for health • Supporting service delivery through improved administration systems • Improvements to public financial management and procurement outcomes • Performance culture and indicators: from a ‘budget’ focus to a ‘performance’ focus
- 10. 10 Source: MHMS, 2011c, 2014c; WHO, 2010b Overview: Infrastructure Health network by province • Majority of health care infrastructure in poor conditions including hospitals, area and rural health centres • Investment on infrastructure is donor dependent • Rate of hospital beds per 1000 population decreasing: 2 beds/1000 population (2006) • NHSP: No comprehensive data on utilization, operating statistics to contribute to NHSP goals of better administrative systems
- 11. 11 Overview: Human resources Source: Asante et al., 2011 Proportion of health care workers by cadre, 2010 • Critical shortage of health workers in the Solomons • Nurse-led primary health system • Doctors largely based in provincial hospitals or NRH • Physicians sent overseas as it is not cost-effective to have training schools in country
- 12. 12 Overview: Human resources Distribution of health personnel by province, 2010 Source: Asante et al., 2011 • Even distribution of health workers (except Guadalcanal and Malaita) • MHMS: drafting first HRH plan for health sector
- 13. 13 Achievements and progress made UHC •On track to achieve UHC •Achieved despite: low per capita expenditure, high delivery costs. Limitations on fiscal spending largely overcome MDG •MDG 1: Improved child nutritional status – achieved. Yet, one-third children remain stunted •MDG 4: Decline in infant mortality and under-5 mortality. Variation in immunisation coverage among provinces remain •MDG5 : Improved maternal health. Corresponding increase in births with assistance of skilled health personnel Outcomes •Steady improvement in health outcomes •High contact rates, low expenditure, improving satisfaction levels
- 14. Achievements and progress made: Financial equity 14 Source: World Bank, 2010 Public hospital inpatient care use by poorest and richest wealth quintiles Source: World Bank, 2010 Public hospital inpatient care use by poorest and richest wealth quintiles • Overall high level of equity and access across income levels • Low OOP payments and catastrophic health spending • All medications are free of charge to citizens • NHSP and SWaP implementation: Strong affordable system, efficient use of government and non-government resources alike and delivers sustainable services
- 15. 15 Achievements & progress: Public Health Programmes Safe Motherhood EPI IMCI Malaria and TB control Healthy Settings • Efficiency improvements: In line with NHSP, national programmes integrating aspects of external agencies, e.g. malaria, water and sanitation
- 16. 16 Achievements & progress: Nurses and nurse aides • Over 50% of the workforce are nurses or nurse aides • 96.5% of all facilities are staffed by nurses and/or nurse aides • Nurses fill a variety of crucial roles in the health system: infection control, public health programmes and filling in gaps in services such as mental health Workforce backbone Disease Surveillance Public health programmes Filling in service gaps
- 17. 17 Achievements & progress: Pharmaceuticals WHO quality assessment on suppliers Free to citizens Low drug stock-outs Higher availability in rural areas Parallel reforms in place • Free medicines for citizens accessing the public health sector • Pre-qualified suppliers are used with WHO based quality assessment • Electronic inventory system allows stock management, future forecasting resulting in low level stock-outs • Parallel health reforms and investments strengthened overall success of operations
- 18. 18 Remaining challenges: Population health concerns Proportion (%) of primary health care clinic attendance by condition Source: Maike, 2010; MHMS, 2012 • Increase in patients presenting with ARI, skin diseases, lower malaria • Lack of appropriate data to assess mortality rates and impact of interventions • Mortality: Malaria: 3/100,000 people; non-HIV TB: 18/100,000 • Early stage of epidemiological transition. 41% of deaths expected from NCDs • “Other” conditions could be hiding rise of NCD prevalence
- 19. 19 Remaining challenges: MCH and adolescent health Source: Maike, 2010; MHMS, 2013, 2014; SISO, 2007; World Bank, 2012a; WHO, 2010b Maternal, child and adolescent health indicators Postnatal care to a newborn at the National Referral Hospital. ©WHO/Yoshi Shimizu
- 20. 20 Remaining challenges: Infrastructure Source for both tables: Nomura S et al., 2017 Hospitals Communicatio n Running water Electricity Oxygen source Anaesthesia machine Operating theatres 12 in total All but Kilu’ufi hospital has phone, internet, Short Wave Radio (SWR). Yes, 5 have had extended disruption of water supply Yes, 3 have had interrupted electricity supply Generally yes, Kilu’ufi has interrupted supply 4 have working machines, 5 do not NRH has four, 3 have no operating theatres at all Source: Adapted from Auto et al., 2006; Natuzzi et al., 2011; Oberli, 2010 Hospital infrastructure, 2014 • Funding gaps for most health facilities lead to poor infrastructure at hospital, AHC and RHC levels. These include disruption of water and electricity supply, and lack of or inoperable machines • 70% of health clinics require significant upgrade, repair or renovation • Donor funding heavily relied upon for investment funding • Consequences: Existing resources and human resources become strained under growing pressures to provide adequate health care
- 21. 21 Remaining challenges: Barriers to planned reforms UHC target: access and financial constraints Shift to performance culture under NHSP: Slow progress, no explicit strategy Human resources: Lack of planning, implications for nurse-led health care
- 22. 22 Remaining challenges: Information reporting • Gender: • National reports not disaggregated by gender • Limited data on which to base firm conclusions, little attention received at national level on health needs • Mortality and morbidity: • Lack of data to assess epidemiological change, or effect of response • Health Information System: • Reliance on manual reports • Duplication of functions by multiple national programmes • Facility reporting: • Baseline data and targets not reported for several indicators makes tracking progress difficult
- 23. 23 Remaining challenges: Quality of care •5% of rural population has access to improved sanitation •Prone to sudden outbreaks of infectious disease NHSP health determinants •Baseline data and targets missing from outpatient services •Assessment tools for health facilities & equipment exist but utilization and follow-up are unclear Information reporting •Health worker to population ratio low •Quality of vaccines due to breaks in the cold chain •Challenges in quality of diagnosis and treatment Health services •Regulations not always implemented •Misuse of already scarce resources Regulation and administration
- 24. 24 Remaining challenges: Finances Strain on health system Low fiscal capacity Limited increase in patient/donor contribution Government outlay on health already high Limited economic growth prospects Administration accountability Poor accounting Inefficient fund use Administrative accountability: • Poor accounting training, petty theft and fraud • Zero tolerance agreement and parallel budget reforms in place Highly inefficient use of funds: • Excessive allocation for capacity building • Not needs based Other • Expected rise in costs & costs of NCDs – challenge in maintaining existing financial protection
- 25. 25 Future prospects: Solomon Islands Prevention & primary care Nurse-led health care MHMS Challenges: Human resource and financial constraints Development: SWAp, Healthy Settings, better admin and public financial management Foundation of the future health system
- 26. Based on the Health Systems in Transition Solomon Islands Health Systems Review, 2015 26
Editor's Notes
- The Solomon Islands, also referred to as “the Solomons”, are a small Pacific state. It is a double-chain volcanic archipelago comprised of more than 900 islands and atolls covering an area of 28370 square kilometres (WHO, 2010b). It shares ocean borders with Papua New Guinea to the west and Vanuatu to the east. The Solomons are prone to earthquakes and tsunamis due its position in the Pacific ‘ring of fire’ (WHO, 2010b; Sade, 2005b). Rising rides and sea levels are also a threat. The population sat at 515870 in 2011 (SISO, 2011a). 80% reside in rural areas though urban growth is occurring at a rapid pace. The country has a young age structure. The median age in 2009 was 20 years old (WHO, 2010b). The total fertility rate (TFR) is high and stands at 4.1 births per woman. Life expectancy has risen steadily for men and women. In 1980, male life expectancy was 58 while female life expectancy was 60. This has risen to 66 and 69 respectively in 2012 (WHO, 2012; World Bank, 2012a). Overall GDP in USD has risen from $168 million in 1980 to $1.096 billion in 2013 highlighting a six-fold growth over this period. It is classified as a low-middle income country but is still heavily dependent on aid (World Bank, 2012b). The GDP per capita (PPP, current) is $3455 USD. Major civil unrest during 1998-2003 caused social and economic declines with thousands displaced and the disruption or destruction of much public infrastructure (Auto et al., 2006b). Health Expenditure as a percentage of GDP is 8% as of 2012. According to the Human Development Index, the Solomons ranked 152 out of 189 countries in 2017 (UNDP, 2018) UNDP link: http://hdr.undp.org/sites/all/themes/hdr_theme/country-notes/SLB.pdf
- The Ministry of Health and Medical Services (MHMS) acts as steward and manager which is appropriate given the population size, fiscal space and geographic context. It is the central actor in the health system. Universal health coverage of an affordable basic package of care is on track despite limited resources. 95% of health financing is supplied by the Government and development partners with 3-4% from out-of-pocket (OOP) payments. The current National Health Strategic Plan (NHSP) 2011-2015 prioritizes prevention and primary care with the aim of building on resilient rural health services and providing better care with little no expected growth. NGOs, faith-based services and the private sector play a small role in the health sector. NGOs and faith-based services work directly with MHMS. Most provinces have at least one level of health facility based on the size and distribution of their population. More than 50% of the workforce is made up of nurses and nurse aides who form the backbone of the health system, and dominate postings in rural areas. This creates an efficient workforce structure with referrals to doctors in larger provincial hospitals.
- A formal referral system exists within the health system. Referrals are made to doctors based in larger provincial hospitals or the National Referral Hospital (NRH). However, many patients often bypass provincial hospitals to go directly to the NRH to receive the highest standards of care available. The utilization rates of inpatient and outpatient care are equally distributed between the richest and poorest quintiles. In outpatient care, health service contact rates are high by regional comparison. 87% of those ill sought care with 85% seeking public sector health services (Maike, 2010). Public health activities, which improve health, quality of life and prolong life and prevent diseases are integrated into the primary care system. Serious shortages of clinical equipment and medical supplies exist at most health facilities. The NRH does not have trained staff or equipment to conduct diagnostic tests other than for malaria. Inpatient care begins in Area health centres (which sit below provincial hospitals in the health system hierarchy) but is limited due to bed and service constraints. Rural health centres have holding beds not designed to be inpatient beds. Specialist hospital care provided at the NRH is from specialist national clinicians or invited specialists. Patients may be referred overseas if appropriate services are unavailable in the Solomons.
- Ministry of Health and Medical Services (MHMS) is the central actor in the health system for the Solomons. It acts as funder, regulator and provider of nearly all services. It is divided into four major divisions: health improvement, health care, health policy and planning and administration and finance. The provincial health offices are responsible for the delivery of primary health care services and outreach programmes in their sector. NGOs, faith-based organizations play significant roles in funding and service delivery but largely collaborate with MHMS. The private sector plays a minimal role in the health sector. There are currently no formal consumer or consumer advocacy groups in the Solomons. Little formal consultation occurs with the public.
- The health system is characterized by moderate levels of health expenditure relative to national income. Health outcomes have been resilient to political and economic crises in recent years. Total health expenditure (THE) was estimated to be $313 million SB in 2009. THE as a percentage of GDP has historically doubled from 1995 at 4.1% to 9% in 2012 (World Bank, 2012b; WHO, 2011a) with overall health expenditure per capita (PPP, current) tripling between 1995 and 2011. The main sources of funding are general government revenue and external donor resources which accounted for 95% of health financing in 2011. In the 2005/2006 Household Income and Expenditure Survey, 1% of total household income was spent on health care each year pointing to minimal out-of-pocket (OOP) payments. This could be the reason for high utilization. There is a good level of financial risk protection and minimal levels of catastrophic health spending. Compared to the East Asia and Pacific region, OOP burden on the poor was lowest in the Solomon islands (<0.05% of monthly household budget) (World Bank, 2010). Government expenditure on health is high and unlikely to grow, with little expected growth in donor financing. The government is experiencing an economic slowdown tied to a decline in logging revenues. A limited fiscal scope combined with high cost of delivery (electricity and transport) are an additional barrier for health system funding growth. Voluntary health insurance accounts for a negligible source of health revenue.
- After a stabilization period following civil unrest, the Government began a new phase of reform under the National Health Strategic Plan (NHSP) 2011-2015. In 2008, the MHMS and key development partners agreed to develop a Sector-Wide Approach to allow aid financing flow through Solomon Islands systems. The objective was to help the Government meet recurrent costs of service delivery, align donor support and conduct evidence-based dialogue about resource allocation and sector performance. MHMS and development partner collaboration has improved (Tyson, 2011; Tyson & Dodd, 2012; Kelly & Tuckwell, 2014) with a rolling programme of policy analysis, surveys and reform as well as a Technical Cooperation Inventory being two areas supporting MHMS leadership and technical assistance. Under the NHSP 2011-2015, prevention became the primary focus of service delivery. The need to plan, cost and implement a basic package of primary care within a low growth scenario at provincial levels was the main priority. The key goals for the NHSP outlined include: Universal Health Coverage – to expand maternal, neonatal and child health, communicable disease and NCD services with a prevention focus. Decentralization of national programmes – For all national public health programmes to integrate service delivery models and prioritize prevention. Better efficiency at NRH and use of human resources– Funding has been capped with a view to improve service quality and efficiency. Staffing has been labelled a top issue but decisions on training and roles have not been addressed. Improved administration systems, public financial management and procurement outcomes– Audits and assessments applied resulting in roadmaps for improvement on a system wide basis, including developing transparency and zero tolerance to fraud. Performance culture and indicators – Shifting from a ‘budget’ focus to a ‘performance’ focus.
- In order of levels of care (from lowest to highest), there are 187 nurse aide posts, 102 rural health centres, 38 area health centres, 7 provincial hospitals, 1 National Referral Hospital (NRH). The provinces have access to a health network based on the size and distribution of the population (Auto et al., 2006a; Natuzzi et al., 2011). The NRH is the largest hospital in the Solomons with 300-400 beds and specialized departments in dentistry, general surgery, gynaecology and obstetrics (Oberli, 2010). The majority of hospitals are in poor condition with a substantial investment in infrastructure for building maintenance and equipment required (Auto et al., 2006a). A 2005 review of area health centres found 70% required significant upgrade, repair or renovation. This was 10% better than a review conducted in 1989 (Waqarakirewa, N.D). A review on rural health centres showed the same trends. 30-40% of THE is allocated to investment funding. Three-quarters of this allocated to infrastructure (MHMS, 2011b; Foster et al., 2009b). This creates a dependency on foreign donors to continue recurrent financing. No comprehensive data exists on utilization and operating statistics but this will change with the Health Facility Costing Study which will contribute to NHSP goals of better administrative systems. Compared to Fiji, Kiribati and Tonga, the number of hospital beds in the Solomons per 1000 population was similar and like them, has been decreasing since 2000. The average number of beds was just under 2.0/1000 population in 2006.
- Nurses form the backbone of the health workforce in the Solomons. There are 2728 health workers in the public health sector. There are 936 nurses and 153 doctors and dentists (Asante et al., 2011). 53% of the workforce is made up of nurses or nurse aids with doctors and dentists only make up 6%. There is a critical shortage of health workers in the Solomons (Georganas, 2010). However, the distribution of personnel is evenly spread across provinces except for Guadalcanal and Malaita (1:425 and 1:432 respectively). Health care workers, mainly physicians, move overseas for better work or training opportunities (Same et al., 2011). Physicians are often sent to Fiji, Papua New Guinea or Cuba as it is not cost-effective for the Solomons to maintain medical and specialist training schools.
- There is a critical shortage of health workers in the Solomons (Georganas, 2010). However, the distribution of personnel is evenly spread across provinces except for Guadalcanal and Malaita (1:425 and 1:432 respectively). The return of 94 doctors trained in Cuba has implications on how the health care services will be provided. The MHMS is completing the first human resource plan to address this.
- Universal health coverage is largely on track in the Solomons. Low per capita expenditure, high delivery costs and limited space to increase fiscal spending has not stopped near universal coverage of the basic care package. Overall, there has been a steady improvement in health outcomes. The health system achieves high coverage with three quarters of the population using public health facilities and around 90% of mothers giving birth in a facility (MHMS, 2014a). The Solomons has also made progress towards meeting their Millennium Development Goals. The goal for improved child nutritional status has already been achieved. The goal for infant and under-five mortality rates is on track with substantial declines in mortality. The maternal health target is also on track with a significant decline in maternal deaths since the 1990s and more mothers giving birth with skilled health personnel assistance (Mishra et al., 2010). The People’s Survey by the Regional Assistance Mission to Solomon Islands (RAMSI) in 2013 found 21% of respondents thought health services had improved a lot in the past five years and 56% thought there had been some improvement (ANU, 2013). Access and utilization compares favourable with other low-income countries. There appear to be no significant differences in immunization coverage by income groups. Neither are rural populations less likely to seek treatment from a health facility. Data from the Household Income Expenditure Survey (HIES) has found no evidence of lower utilization by the poor (next slide).
- The Solomon Islands health system has provided a relatively resilient financial risk protection scheme, even in the face of political unrest. The system has delivered a very low rate of OOP payments which is believed to have to led to high contact rates with health facilities, negligible rates of catastrophic health spending and above-average health outcomes relative to income per capita. The Solomons is one of the few countries in the region where inpatient and outpatient care use is not adversely affected by income level. OOP payments do not represent a significant burden on citizens. Households in the poorest income quintile allocate less than 0.05% of their household budget to health care expenses (World Bank, 2010). This creates a relatively equitable system. The 2006 House Income Expenditure Service found that nearly 87% of people sought care when ill and overall satisfaction is high. All medications are free of charge to citizens accessing the public health system. All of them are imported as no local manufacturing exists. The NHSP and SWaP system have enabled the Solomons to move towards a strong, affordable system. This means that it makes the best use of all resources, uses government and non-government resources efficiently and does not try to deliver unsustainable services.
- The MHMS conducts a series of public health programmes through facilities, tours and community-level Healthy Settings activities. These include the Safe Motherhood programme, Expanded Programme on Immunization (EPI), Integrated Management of Childhood Illnesses (IMCI), nutrition, malaria and tuberculosis control. The Safe motherhood programme covers family planning including antenatal care, obstetric care, postnatal care, STIs/reproductive tract infections and HIV control (MHMS, 2006). The programme is aligned with the WHO Global Reproductive Health Strategy Activities which includes training of nurses, surveys, intervention and protocols for obstetric/gynaecological complications (MHMS, 2006). The EPI provides weekly immunization clinics, measles campaigns and a once a year ‘catch up’ campaign (Jack, 2011b). The IMCI focuses on early child health including vaccines, feeding recommendations and management of malaria, diarrhoea and pneumonia (Jack, 2011b). By 2007, 18 facilitators and 197 first-level health workers had been trained across seven provinces (MHMS, 2007c; Jack, 2011b). 81% of 12-23 month old children were fully vaccinated by 2007. The MHMS works with partners to address vector-borne disease control including malaria and tuberculosis. The Solomons has already reached the WHO Western Pacific Region goal to reduce by half the morbidity and mortality from all forms of TB by 2015, relative to 2000 levels. Malaria levels have also been reducing steadily since 2009 (WHO, 2013b; Mishra et al., 2010). The Healthy Settings programme aim is to adopt healthy behaviours in villages, schools, towns, health facilities and workplaces. By encouraging people to care for their own health and having the right range of services in place, sustained improvements in outcomes can occur in the medium-long term. Efficiency improvements: In line with NHSP, national programmes integrating aspects of external agencies, e.g. malaria programme into provincial services, water and sanitation services are contracted out to NGOs.
- Nurses form the backbone of the health system in the Solomons. Nurses and nurse aides provide the majority of care. Nurse aide posts, RHCs and AHCs are all staffed by nurses and/or nurse aides. Together, Nurse aide posts, RHCs and AHCs add up to 96.5% of all facilities in the Solomons (MHMS, 2011c, 2014c; WHO, 2010b) highlighting their importance within the system. This workforce structure, which includes referral to doctors in larger hospitals, meets WHO guidance and is cost-effective. More than 50% of the health workforce are nurses or nurse aides (Asante et al., 2011). This can be seen in other Pacific Island Countries and Territories with a similar population size such as Fiji and Vanuatu (WHO, 2009). Infection control nurses also play a crucial role in disease notification and surveillance including identifying potential disease threats by monitoring trends and identifying and investigating outbreaks. They also form a crucial part of the public health programme activities initiated by the MHMS. These include the Safe motherhood programme as family planning nurses and as ICMI health workers. Nurses also fill in gaps of other services including mental health care which provincial hospitals do not reserve beds for. Instead, trained mental health nurses deliver public education, clinical care and referral in six provinces. Delivery of specialist outreach programmes is dependent on the nurse and medical staff skills at that particular location (Waqatakirewa, N.D.).
- Pharmaceutical provision is managed by the MHMS National Pharmacy Services Division (NPSD). The overall goal is to ensure complete, equal and safe access to essential medicines (MHMS, 2011f). All medications are free of charge to Solomon Islanders accessing the public health system. There are only a few private pharmacies in the country. Quality assurance is performed through the use of pre-qualified suppliers based on a WHO model of assessment. The National Medical Stores (NMS) which has the responsibility of overseeing operations (MHMS, 2008a) uses an electronic inventory system to track stock called mSupply. This tool is used for stock management, to forecast future consumption, track usage and expiries and ensure distribution to facilities. It also allows for dispensing and patient history record keeping at hospitals. This has contribute to low drug stock-outs at facilities. At Second Level Medical Stores (SLMS), mSupply Mobile is used to manage inventories, place and manage orders for clinics. SLMS are staffed by pharmacy officers who provide medicine-related information to the public and health professionals. The NPSD has launched National Pharmacy standards, infrastructure projects, training in stock management and building and refurbishing eight SLMS (MHMS, 2011f). This has increased storage space, security for storing and distributing large volumes of pharmaceuticals while ensuring uniform standards are applied across health facilities (MHMS, 2011f). NMS infrastructure is now inadequate and excess stock is placed aboard shipping containers. The availability of medicines in rural areas is improving.
- A lack of comprehensive and reliable mortality data means it is difficult to assess changes in causes of death or to attribute improved health outcomes to specific policy interventions. No data exists on variations in mortality rates by socioeconomic or ethnic status (Thomas & Duituturaga, 2014). Mortality rates from malaria was 3/100000 in 2012 and from non-HIV-positive tuberculosis it was 18/100000 population in 2009 (WHO, 2012; MHMS, 2013). The Solomons are at an early stage of epidemiological transition. An estimated 51% of mortality rates occur due to communicable diseases, 41% from noncommunicable diseases(NCDs) and the remainder from injuries (8%) (WHO, 2012). 31% of the population report daily smoking and 25% of the male population reported consuming five or more alcoholic beverages per day within the previous week. Burden of disease is largely made up of acute respiratory infection (ARI), clinical malaria and skin diseases. While malaria rates have decreased from 18% to 10% of those presented at primary health care clinics between 2001 and 2011, ARI has increased from 21% to 31% and skin diseases from 5% to 12% in the same period. The classification of “Other” diseases could be hiding the true burden of disease such as NCDs.
- The Solomons has a young, rapidly growing population. Its young population, including its increasing numbers of young women reaching reproductive age increases the need for maternal and child health services. The country has a high rate of maternal mortality for out-of-facility births though utilization rates of maternal and child health service indicators are high. Maternal mortality rates have dropped significantly from 1990 at 550/100000 but still remains high 99.7/100000 live births in 2013. Infant mortality has dropped from 96/1000 live births to 10.6 over the same period (See table above). A growing adolescent fertility rate from 57.1 births per 1000 women aged 15-19 years in 2000 to 66.0 in 2011 is also cause for concern. Combined with a low level of contraceptive prevalence rate (27% of married women aged 15-49), this can create greater risk of STI spread.
- The majority of hospitals, AHCs and RHCs are in very poor condition. Most hospitals require a high level of investment for maintenance of buildings and equipment (Auto et al., 2006a). Many hospitals rely on generators for power and often can only rely on them during the day due to cost, power outages. Access to running water is also limited throughout the country and in hospitals. 80% of hospitals have rainwater-collecting tanks (Auto et al., 2006a). Gizo Hospital and NRH’s plumbing needs to be repaired as some parts of the hospital wards have no tap water access. A 2005 review of AHCs found up to 70% of health clinics required significant upgrade, repair or renovation. This is 10% better than a review conducted in 1989 (Waqatakirewa, N.D.) While some health facilities have been damaged by cyclones and other natural disasters, most are not properly or regularly maintained due to lack of funding (Waqatakirewa, N.D.; JTAI, 2006). A RHC review showed the same trends as in the AHC review including poor infection control, hygiene and waste disposal as well as unfit or inappropriate birthing facilities. Development partner contributions are heavily relied upon for investment funding and this dependency can only up funding gaps for buildings and equipment alike. There are serious shortages of medical equipment and medicine supplies at most health facilities. Most hospitals rely on old and poorly maintained medical, diagnostic and surgical equipment. 5 of 12 hospitals do not have working anaesthesia machines while 3 have no operating theatres at all.
- Reform in the health system is aimed at prioritizing prevention and primary care. This entails shifting resources and changing what health workers do. However, there are several challenges in implementation. To achieve universal health coverage, a higher level of financing will be required. The average distance a patient must travel to get treatment at the NRH is more than 240km (Natuzzi et al., 2011). A shortage of roads and transport between islands adds to time and financial constraints for patients. Furthermore, high delivery costs including electricity and transport also limit the fiscal scope of the health system. The NHSP has shifted to a performance culture from a ‘budget’ culture. This aims to inculcate a better quality of care agenda as opposed to services constrained by a budget. However, no documented strategy for developing performance orientation across the sector or to clarify intentions exist. Better dialogue is occurring due to improvements in the health information system and financial reporting about resource allocation and performance both within the health system and across government. However, progress is slow. The MHMS is completing its first human resource plan for the sector linking it with planning, development and management (MHMS, 2011e). However, there is no provision in the national budget or health services for returning Solomon Islanders sent to Cuba for medical training. This carries greater implications for how the nurse-led provincial health system will continue to work in the future.
- Gender inequality information and reporting is low. There is little survey data or information from other sources to help understand issues women face, especially in rural areas. They continue to face difficulties in accessing family planning services and have received little attention by the national health sector policy alongside poverty and ethnic inequality. Health-related gender inequalities also mean high fertility rates and limited information on preventative care (Maike, 2010). Data presented in national plans and reports is not disaggregated by gender. There is a lack of comprehensive and reliable mortality data meaning it is hard to assess changes in the causes of death or attribute better health outcomes to specific policy interventions. No data exists on mortality rates by socioeconomic status or ethnicity (Thomas & Duituturaga, 2014). The Health Information System (HIS) still relies on health facilities sending manual reports to provincial hospitals where data input occurs. Software has started to be rolled out so data can be entered on site via the internet. Several public health programmes capture and analyze their own data creating duplication of costs (JTAI 2006; MHMS, 2011e). Baseline data and targets are unavailable for outpatient department service utilization, the number of centres offering basic emergency obstetric care. This creates issues for tracking of progress of health outcomes.
- The NHSP 2011-2015 has a number of hurdles to overcome to ensure high quality of care across the health system: Determinants of health – only 5% of the rural population has access to improved sanitation (MHMS, 2011e). Overall, urban areas have 77% sanitation coverage compared to 5% in rural areas (Jack, 2011b). Baseline data and targets are missing from outpatient services. Until programmes have regular support, supervision and performance monitoring, quality of care will be an issue Health status – Tuberculosis and other infectious diseases continue to be a serious problem and are prone to sudden outbreaks. Health worker to population ratio is very low While health service utilization is high, there are problems with invalid vaccines due to broken cold chain and questionable validity of diagnosis and treatment (Foster, Chamberlain et al., 2009). Tools exist to assess quality of equipment and status of health facilities but implementation and follow-up are unclear. A recent review of RHCs (2012) found no incinerators and significant numbers of facilities without sterilizers. Improvements in systems and transparency have been effective in identifying and demonstrating the impact of corruption. Misuse of scarce resources directly affects care quality but while it is recognized, real behaviour change is yet to be seen. Regulations are in place to ensure health concerns are addressed including the Mental Health Treatment Act and the Environmental Health Act. However, these have not always been translated into practice. For example, there are no specialized mental health inpatient departments at provincial departments.
- The fiscal space for health is unlikely to grow due to a number of factors: Government outlays on health are already high by international standards at 8% in 2012 (World Bank, 2012b; WHO 2011a) Limited economic growth prospects following the global downturn in 2007-08 Limited expected increase in patient and donor financing A recent audit found a number of issues identified in a 2005 audit of the MHMS remained. These include poor accounting due to limited or no formal training, widespread low-level petty theft adding up to a small percentage of total spending (DFAT, 2013). In 2011, AusAID reported 19 cases of fraudulent use of donor funds between 2004/05 and 2010 (Anonymous, 2011). A substantial fraud case amounting to $10 million SB was discovered in 2013 but a zero tolerance agreement appears to be having an impact. Reforms to public financial management in cash management, budget integration, accounting and audit functions are in progress. A relatively high allocation of funding to in-service training and workshops involves the UN and Secretariat of the Pacific Community (SPC) contributing workshop coordinators and training providers. This is highly inequitable, inefficient and the same may apply to pre-service training. There is considerable scope for savings by creating an integrated in-service training programme. Here, the UN and SPC could provide curriculum development and teaching support to identify and build sustained skills and expertise. Geographic distribution of funds is also inefficient. Honiara receives the highest amount of health spending but a recent survey and health information system data highlights Malaita has greater health outcome and service delivery needs while accounting for 30% of the population. Yet it receives a significantly lower share than expected (World Bank, 2010b). This forces patients to bypass facilities and to go to the NRH directly. External advisers and partners can also drive up costs by pressuring the government to include new expensive vaccines with little overall benefit in health outcomes. Other issues include inefficient utilization of staff in some facilities and a weakly developed service model for Healthy Setting activities while some activities such as family planning appears to be underfunded. Expectation of rising costs of health, including future costs of NCDs creates a risk that current levels of financial protection will not be able to be maintained.
- While the current unified, blended health system with the MHMS as steward and manager has been deemed appropriate for its population size, fiscal space and geographic context, there are a number of developments that need to occur to provide sustainable health care in the future. The focus on prioritizing prevention and primary care should remain as under the NHSP. Greater clarity in administrative systems, roles and responsibilities can underpin effective management and deliver better health outcomes. The basic characteristics of the primary care system should be kept with a high level of emphasis on nurse and nurse aide roles but also the referral system and provincial health offices. Planning and implementation of efficiencies should not undermine equity. The main challenges faced by the government are financial and human resource constraints. The volatile financial situation along with increasing disability, hardship and vulnerability, urbanization and a rise in NCDs with slowing growth are all expected. Public financial management, including reporting and auditing should be improved to ensure financial sustainability of the system. Greater planning and budgeting is required for returning overseas medical staff. There are concerns that doctors trained in Cuba could replace existing nurses creating an imbalance in health workforce distribution and utilization. The first human resource plan for the sector is underway. While reviews on SWAp have recommended improvements, it is agreed that the basic framework should remain. It will also lead to better attaining better baseline data to inform policy choices and build towards a performance culture for development partners and citizens. The Healthy Setting interventions should be strengthened through funding and partnerships which will save the most money in the long run. By budgeting and planning with the private (including UN) sector, it can contribute to prevention and primary care successes.